SARS-CoV-2 variant of concern type and biological sex affect efficacy of molnupiravir in dwarf hamster model of severe COVID-19

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Abstract

SARS-CoV-2 variants of concern (VOC) have triggered distinct infection waves in the coronavirus disease 2019 (COVID-19) pandemic, culminating in currently all-time high incidence rates of VOC omicron. Orally available direct-acting antivirals such as molnupiravir promise to improve disease management and limit SARS-CoV-2 spread. However, molnupiravir efficacy against VOC delta was questioned based on clinical trial results and its potency against omicron is unknown. This study evaluates molnupiravir against a panel of relevant VOC in three efficacy models: primary human airway epithelium organoids, the ferret model of upper respiratory disease, and a lethal Roborovski dwarf hamster efficacy model of severe COVID-19-like acute lung injury. All VOC were equally efficiently inhibited by molnupiravir in cultured cells and organoids. Treatment consistently reduced upper respiratory VOC shedding in ferrets and prevented viral transmission. Pathogenicity in the dwarf hamsters was VOC-dependent and highest for gamma, omicron, and delta with fulminant lung histopathology. Oral molnupiravir started 12 hours after infection resulted in complete survival of treated dwarf hamsters independent of challenge VOC. However, reduction in lung virus differed VOC-dependently, ranging from one (delta) to four (gamma) orders of magnitude compared to vehicle-treated animals. Dwarf hamsters infected with VOC omicron showed significant individual variation in response to treatment. Virus load reduction was significant in treated males, but not females. The dwarf hamster model recapitulates mixed efficacy of molnupiravir seen in human trials and alerts that therapeutic benefit of approved antivirals must be continuously reassessed in vivo as new VOC emerge.

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  1. SciScore for 10.1101/2022.02.04.479171: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIACUC: Experiments with SARS-CoV-2 involving ferrets and dwarf hamsters were approved by the Georgia State Institutional Animal Care and Use Committee under protocol A20031 and A21019, respectively.
    Sex as a biological variableLonza Bioscience, cat# CC-2540S, lot# 0000646466, passage 3, donor “M4”) from a 38-year-old male were expanded in PneumaCult-Ex Plus (Stemcell Technologies cat# 05040) and differentiated in PneumaCult-ALI (Stemcell Technologies cat# 05001) for 8 weeks in following the manufacturer’s instructions.
    RandomizationAfter a minimal resting period of 2 weeks after arrival, animals were randomly assigned to groups for individual studies, transferred into an ABSL-3 facility immediately prior to study start, and housed singly in ventilated negative-pressure cages during the studies.
    Blindingnot detected.
    Power Analysisnot detected.
    Cell Line AuthenticationContamination: All cells were authenticated and checked for mycoplasma prior to use.

    Table 2: Resources

    Antibodies
    SentencesResources
    Antibodies: SARS-CoV-2 N and goblet cells were co-stained using rabbit anti-SARS-CoV-2
    anti-SARS-CoV-2
    suggested: None
    Nucleocapsid monoclonal antibody (HL453) (Invitrogen, cat# MA5-36272) (1:100 dilution) and mouse anti-MUC5AC (ThermoFisher, cat# MA5-12175) (1:200 dilution) as primary antibodies, respectively.
    HL453
    suggested: (Thermo Fisher Scientific Cat# MA5-36272, RRID:AB_2890568)
    anti-MUC5AC
    suggested: (Thermo Fisher Scientific Cat# MA5-12175, RRID:AB_10983421)
    Donkey anti-goat (Alexa Fluor® 568 (ThermoFisher Scientific, cat# A-11057)) and rabbit anti-mouse IgG (H+L) cross-adsorbed secondary antibody (Alexa Fluor® 488 (ThermoFisher Scientific, cat# A-11059)) were used at a 1:500 dilution as secondary antibodies.
    anti-goat
    suggested: (Molecular Probes Cat# A-11057, RRID:AB_142581)
    For staining of SARS-CoV-2 S, mouse anti SARS-CoV-1 and 2 Spike protein clone [1A9] monoclonal (Abcam, cat# ab273433) (1:200 dilution) and goat anti-mouse IgG (H+L) highly cross-adsorbed secondary antibody (Alexa Fluor® 488; 1:500 dilution (Invitrogen, cat# A-11029)), were used as primary and secondary antibodies, respectively.
    anti SARS-CoV-1 and 2 Spike protein
    suggested: (Abcam Cat# ab273433, RRID:AB_2891068)
    anti-mouse IgG
    suggested: (Molecular Probes Cat# A-11029, RRID:AB_2534088)
    For staining of ciliated cells, rabbit anti-beta IV tubulin recombinant antibody conjugated with Alexa Fluor® 647 [EPR16775] (Abcam, cat# ab204034) was used at a 1:100 dilution.
    rabbit anti-beta IV tubulin recombinant antibody
    suggested: None
    anti-beta IV tubulin
    suggested: (Abcam Cat# ab179509, RRID:AB_2716759)
    Experimental Models: Cell Lines
    SentencesResources
    Cells: African green monkey kidney cells VeroE6 (ATCC CRL-1586™),
    VeroE6
    suggested: None
    VOC delta (lineage B.1.617.2, clinical isolate #2333067) and VOC omicron (lineage B.1.1.529, WA-UW-21120120771) were obtained from the Northwestern Reference laboratory and amplified on Calu-3 cells.
    Calu-3
    suggested: BCRJ Cat# 0264, RRID:CVCL_0609)
    For hamsters infected with VOC gamma, delta, and omicron, plaque assays were performed with VeroE6-TMPRSS2 cells.
    VeroE6-TMPRSS2
    suggested: JCRB Cat# JCRB1819, RRID:CVCL_YQ49)
    Software and Algorithms
    SentencesResources
    Log viral titers were normalized using the average top plateau of viral titers to define 100% and were analyzed with a non-linear regression with variable slope to determine EC50 (Prism; GraphPad)
    GraphPad
    suggested: (GraphPad Prism, RRID:SCR_002798)
    Image captures were performed with a Zeiss Axio Observer Z.1 and an LSM 800 confocal microscope with AiryScan, controlled with the Zeiss Zen 3.1 Blue software package (Windows 10).
    Zen
    suggested: None
    Statistics and reproducibility: The Microsoft Excel (versions 16.52) and Numbers (version 10.1) software packages were used for most data collection.
    Microsoft Excel
    suggested: (Microsoft Excel, RRID:SCR_016137)
    Numbers
    suggested: (BioNumbers, RRID:SCR_002782)
    The GraphPad Prism (version 9.1.0) software package was used for data analysis.
    GraphPad Prism
    suggested: (GraphPad Prism, RRID:SCR_002798)
    Figures were assembled using Adobe Illustrator (version CS6).
    Adobe Illustrator
    suggested: (Adobe Illustrator, RRID:SCR_010279)

    Results from OddPub: Thank you for sharing your data.


    Results from LimitationRecognizer: An explicit section about the limitations of the techniques employed in this study was not found. We encourage authors to address study limitations.

    Results from TrialIdentifier: No clinical trial numbers were referenced.


    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.


    Results from JetFighter: We did not find any issues relating to colormaps.


    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.


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